Cervical Spine Surgery 101

France EllysonKuwait 2014

Introduction

Degenerative cervical spine disease is a common problem associated with aging

Often asymptomatic or experienced as episodic neck pain

Peak incidence among 50-54 years of age Most common etiology spondylosis Usually 6 weeks of conservative treatment is

recommended before surgery is considered

Cervical Spine Anatomy

Cervical spine has 7 vertebrae

Body is located anteriorly

To either side of body – transverse process

Vertebral foramen – known as spinal canal

C1 Vertebra C2 Vertebra Atlas Axis

Cervical Spine Anatomy

Intervertebral disc resides between each cervical vertebral bodies except C1 and C2

Disc permit flexion and rotation

Composed of nucleus pulposus and annulus fibrosus

Cervical Spine Anatomy

Ligaments between vertebral bodies maintain discs in place

Instrumental in spine alignment

Spinal cord extends from foramen magnum to ?_________

Cervical Spine Anatomy

The meninges cover the spinal cord

CSF bathes spinal cord and is found in SA space

There are 8 pairs of cervical spine nerve roots

A dermatome is an area of skin innervated by fibers of individual nerve root

Dermatomes

Diagnostic Studies

Plain radiography: Inexpensive and non-invasive – shows arthritis and bony alignment

CT scan: Used as adjunct to MRI or in pts who cannot undergo MRI

MRI: Study of choice. Contrast agents may be used to highlight masses, abnormal tissue or fluid collection

Bone scan: Assess increased bone production, tumor, infection

EMG: Assess muscle activity and nerve conduction Somatosensory Evoked Potentials: Evaluates function of

sensory fibers

Cervical Spine Disorders

Neck pain is common problem, often episodic and self-limiting

Can be a symptom of degenerative cervical disorders, neoplastic disease, deformity or infection

Neck Pain without Radiculopathy

Mechanical Pain: Associated with spine Usually deep and

agonizing Aggravated by

activity Alleviated by rest Usually associated

with degenerative conditions

Myofascial Pain Associated with muscle Often results in

muscular spasms and posterior occipital H/A

Best respond to exercise and stress-reducing interventions

Cervical Radiculopathy

Radiculopathies are the result of nerve root compression

In cervical spine, the most common cause is foraminal narrowing and impingement onto spinal nerve

25% cases result HNP Majority of cases caused by cervical spondylosis S/S include – neck pain and upper extremity pain

Cervical Myelopathy

Myelopathy results from spinal cord compression Usually caused by acute disc herniation S/S: hyperreflexia, poor coordination or lack of

motor dexterity, bowel or bladder changes balance problems, falling episodes, varying degree of weakness and sensory changes

Degenerative Cervical Spine Disorders

Herniated Nucleus Pulposus – Bulging, protrusion, sequestered fragment, radiculopathy

Spondylosis – Age- and use-related degenerative changes in spine

Cervical Stenosis – Narrowing of spinal canal, congenital or degenerative changes

Cervical Spine Disease

Rheumatoid Arthritis – chronic systemic autoimmune disease characterized by erosive synovitis that destroys joints in body

Metastatic – Spinal involvement can lead to vertebral collapse and instability, causing pain and potential neurological compromise

Osteoporosis – Low bone mass and structural deterioration

Infection – Hematogenous spread from urinary tract, skin, cardiac valve, abdominal, postsurgical

Nonsurgical Medical Treatment

Non-surgical treatment is warranted for 6-12 weeks unless progressive neurologic deficit

Promotion of smoke cessation

Promotion of weight management

Promotion of adequate physical activity

Non-Surgical Spine Disorders

Medication – Muscle relaxants to reduces spasm, NSAIDs to reduce inflammation of nerve root, opioids for sort-term acute pain

Epidural Steroid Injections – Interlaminar injection of corticosteroid, methylprednisone to inhibit prostaglandin sythesis and decrease immunologic response – Significant success rate but complication may be severe

Nonsurgical Medical Treatment Physical Therapy – PT often reduces pain and improves

function Spinal Manipulation – Chiropractic or ostheopathic –

strong evidence for the benefit of multimodal approach Bracing – Short-term (<2weeks) immobilization with

either soft or hard collar may be recommended Acupuncture – ? Influence the body’s electromagnetic

field which can alter chemical neurotransmitters. Evidence is emerging. (Irnich et al.,2001;White, Lewith, Prescott & Conway, 2004)

Surgical Treatment

Indicated persistent S/S despite conservative Rx

Several studies inconclusive – whether risks of surgery offset benefits

Anterior Approach

Cervical Discectomy (ACD) with and without Fusion (ACDF)

To relieve pressure on spinal cord and nerve roots

ACDF uses graft material (Ileac crest) and plate fixation to prevent disc prolapse

Many surgeons now favor interbody fusion devices and cages

Anterior Approach

Corpectomy – removal of one or more vertebral bodies and adjacent disks - requires stabilization with graft or hardware

Disc Arthroplasty – Artificial disc is an alternative to bone grafts and hardware. New technique in USA

Posterior Approach

Laminectomy with or without Fusion – Removal of the vertebral lamina to decompress spinal cord,

Laminectomy may include fusion if concerns cervical stability (screws, rods, bone)

Grafts Materials

Autograft – From recipient’s own body, usually ileac crest

Allograft – Cadaver bone Biologics –

Demineralized bone matrices, recombinant human BMP

Instrumentation – plates, rods, screws, wires, etc

Preoperative Care

Preop teaching – Surgical procedure, informed consent, anticipation of postop needs (home help, ?driving)

OT consult if cervical collar ordered (remind to bring to hospital)

Consult anesthesia – if unstable C-spine D/C medications; herbal products, NSAIDs,

anticoagulants, aspirin, warfarin, plavix Antibacterial pre-op shower, remove nail polish NPO after midnight prior to OR

Intraoperative Care

Perform “Time out” Verify that prophylactic DVT prevention is

implemented PRN – TEDs, SCDs Verify that preoperative antibiotics are

administered PRN Alert staff of patient allergies PRN Monitor patient positioning

Postoperative Care

Monitor neurological status – compare to preop – focus on upper extremity strength and sensation

Administer antibiotics as ordered – MD specific and controversial

Monitor complications – hematoma or swelling at incision, CSF leak, wound infection

Anterior Posterior

Assess airway patency – dysphagia, sore throat, pain, lump feeling when swallowing, excessive phlegm, production, hoarse voice

Monitor incision for swelling and drainage

Collar PRN

Expect rather lengthy incision 10-15 cm)

Monitor incision site for serosanguinous drainage

Pain ++ at incision site along with posterior cervical muscle spasm

Collar PRN

Postoperative Care

Mobility – varies greatly on diagnosis, preop mobility and type of surgery, ie, single-level ACDF may be ready to mobilize 2 hours after return to in-pt unit

Monitor pain and provide analgesics as ordered Encourage oral feeding as soon as tolerated Prevent constipation – ensure adequate water

intake, diet should include fruits, vegetables and fiber

Administer stool softeners (Ducosate) / motility (Senna) agents as ordered

Postoperative Care

Remove Foley catheter until patient can stand to void, use bedpan or urinal. Goal: D/C Foley catheter within 24 hours of surgery

Assess adequate bladder emptying – use bladder scan Discharge planning: Mobility restrictions if any –

avoid heavy lifting , avoid excessive neck flexion, such as reading, desk work. Ensure computer is at right height.

Reinforce incision care to patient and caregivers – evaluate for S/S infection

Postoperative Care

Collar maintenance: Pts should wear collar at all times. Sometimes they may remove to shower or sleep, at MD’s discretion.

Teach pt how to clean pads and change collar in front of mirror

Aspen Collar

http://www.youtube.com/watch?v=UUd2JNMPWLM

References

Bader, M.K., & Littlejohns, L.R. (Eds.). (2004). AANN core curriculum for neuroscience nursing (4th ed.). St-Louis, MO: Elsevier Health Sciences

Hickey, J.V. (2006) The Clinical Practice of Neurological and Neurosurgical Nursing. Lippincott.

American Association of Neuroscience Nurses [AANN]. (2011). Cervical Spine Surgery: A Guide to Preoperative and Postoperative Patient Care. AANN clinical practice guideline series.